a nurse is assessing a client who has been diagnosed with obsessive compulsive disorder ocd the client states i know my behavior is unreasonable but i
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Nursing Elites

ATI RN

ATI Mental Health Practice B

1. A client with obsessive-compulsive disorder (OCD) tells the nurse, 'I know my behavior is unreasonable, but I can't help it.' What response should the nurse provide?

Correct answer: D

Rationale: The nurse should acknowledge the client's awareness of the irrationality of their behavior and the feeling of powerlessness to change it. By reflecting the client's feelings, the nurse validates them and opens a discussion on strategies to manage the behavior effectively. Empathy and understanding are key in supporting clients with OCD. Choice A is incorrect because it focuses more on changing the behavior rather than acknowledging the client's feelings. Choice B is incorrect as it does not directly address the client's sense of powerlessness. Choice C is incorrect as it doesn't validate the client's feelings of being unable to control the behaviors.

2. A psychiatric nurse observes that a client diagnosed with schizophrenia is pacing up and down the corridor. The client is muttering to himself, and his hands are trembling. Which of the following actions should the nurse take first?

Correct answer: D

Rationale: The first action the nurse should take is to remove the client to a quieter environment. This intervention aims to reduce stimuli that may be contributing to the client's agitation and help create a calmer and more supportive setting for the client. Choices A, B, and C are not the priority in this situation as addressing the environmental factors should come first before exploring symptoms, offering medication, or engaging in relaxation exercises.

3. Which of the following would be the most appropriate intervention for a patient experiencing severe anxiety?

Correct answer: C

Rationale: During a severe anxiety episode, it's crucial to stay with the patient and create a quiet environment. This approach helps reduce anxiety by providing a sense of safety and support. Encouraging the patient to talk about their feelings may not be effective during an acute episode of severe anxiety. Using a firm, authoritative approach can escalate the situation and worsen the anxiety. Suggesting distractions like watching TV may not address the root cause of the anxiety or provide the necessary support.

4. Which of the following statements should a healthcare professional recognize as true about defense mechanisms? Select the one that doesn't apply.

Correct answer: B

Rationale: Defense mechanisms are employed by the ego in the face of threats to biological and psychological integrity to relieve mild to moderate anxiety. They act as protective devices for the ego, not the id or superego. The id represents primal instincts, while the superego is associated with moral standards. Defense mechanisms help individuals cope with stressors by redirecting focus and are often unconscious and self-deceptive.

5. Which client statement should alert a nurse that a client may be responding maladaptively to stress?

Correct answer: A

Rationale: The correct answer is A. Reliance on social isolation as a coping mechanism is maladaptive and can hinder the development of appropriate coping skills and access to support systems. It may indicate a lack of healthy coping strategies and social connections, which are important for managing stress effectively. Choice B is a positive coping strategy that promotes self-reflection and emotional expression. Choice C reflects a proactive approach to managing stress through physical activity. Choice D shows a willingness to seek professional help, which is a healthy coping mechanism.

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